Laserfiche WebLink
commerce.wi.gov <br /> it <br /> 'S c 011 s i <br /> County <br /> Safety and Buildings Division Dane <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707-7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce 13-2021-00186 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned Project Address(if different than mailing) <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> HOLLY M POAST 0906-361-9650-0 <br /> Property Owner's Mailing Address Property Location <br /> 9429 BLACKHAWK TRL Govt Lot. <br /> City,State Zip Code Phone Number SE 1/4 NE 1/4 Section 36 <br /> SAUK CITY,WI 53583 Not Provided Township: 09 N: Range: 06 E <br /> II.Type of Building(check all that apply) Lot Number Subdivision Name <br /> 1 <br /> ECJ 1 or 2 Family Dwelling-Number of Bedrooms: 4 <br /> Block Number CityNillage/I'own of <br /> ❑ Public/Commercial-Describe Use: <br /> CSM Number <br /> ❑ State Owned-Describe Use: 13518 <br /> III.Type of Permit:(Check only one box on line A.Complete line B if applicable) <br /> 0 Replacement 0 Other Modification to Existing System(explain) <br /> A. 0 New System System 0 Treatment/Holding Tank Replacement Only <br /> Permit Renewal Change of Permit Transfer to List previous Permit Number and Date Issued <br /> B. 0 Before Expiration ❑ Permit Revision 0 Plumber 0 New Owner - <br /> IV.Type of POWTS System/Component/Device:(check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component: 0 Pretreatment device: <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.6 1,000 1,000 101.5 <br /> Capacity in Gallons Total #of ci o <br /> VI. Tank Info: Gallons Units Manufacturer Ti c un <br /> New Tanks Existing Tanks U in w <br /> Septic/Holding Tank 1,286 0 1,286 1 Meade ✓ <br /> Dosing Chamber 650 0 650 1 Meade ✓ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Plumber's Business Phone <br /> Andrew Meinholz Permit application completed online 220165 (608)831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee,WI 53597- <br /> VIII.County/Department Use Only <br /> 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ECJ Approved <br /> 0 Owner given reason for denial $ 1,360.00 06/24/2021 Joseph Boebel <br /> IX.Conditions of Approval/Reason for Disapproval <br /> Approved <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size. <br /> I <br />